Transplant recipients have a lower risk of fatal and nonfatal cardiovascular events compared with waitlisted patients on dialysis [1-4], but a much higher risk compared with the general population [5]. Fifty to 60 percent of posttransplant deaths are directly attributable to cardiovascular disease, with an incidence of ischemic heart disease of approximately 1 per 100 person-years at risk [6,7]. Cardiovascular disease is the most common cause of death with graft function after transplant and accounts for 30 percent of graft loss from death overall, with the greatest rates early after transplant [8]. Notably, the incidence of cardiovascular death after transplant appears to be declining somewhat despite the aging and increased comorbidity burdens among transplant recipients, which may reflect advances in medical management or competing risks of cancer and infection [9,10].

The high rate of cardiovascular deaths in the transplant population is due in part to the large number of diabetic patients in the end-stage renal disease (ESRD) population, who are at markedly increased cardiovascular risk, compared with nondiabetic transplant recipients. As an example, in one study of 933 predominantly living-donor transplant recipients, cardiovascular disease was the most common cause of death among diabetic recipients; by contrast, most deaths among nondiabetic recipients were due to infection, malignancy, or other causes [11].

However, the cardiovascular risk among transplant recipients who do not have ESRD related to diabetes is still higher than in the general population [8]. The increased cardiovascular risk is due to the following:

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